Podcast
Questions and Answers
What is the immediate priority when addressing the client's nausea?
What is the immediate priority when addressing the client's nausea?
- Reposition the client on her side (correct)
- Reposition the client on her back
- Check the tube for functionality (correct)
- Administer antiemetic medication
What method describes the correct transfer procedure for an elderly client with left-sided weakness?
What method describes the correct transfer procedure for an elderly client with left-sided weakness?
- Move the chair parallel to the right side of the bed, and stand the client on the right foot. (correct)
- Place the chair at a right angle to the bed on the client's left side before moving.
- Have the client place the left foot next to the chair and pivot to the left before sitting.
- Assist the client to a standing position, then place the right hand on the armrest.
Which statement is accurate regarding the use of complementary healing practices?
Which statement is accurate regarding the use of complementary healing practices?
- Complementary healing practices interfere with the efficacy of the medical model of treatment.
- Many complementary healing practices can be used in conjunction with conventional practices. (correct)
- Conventional medical practices will ultimately replace the use of complementary healing practices.
- Conventional medications are likely to interact with folk remedies and cause adverse effects.
After determining a client has a problem, which action should the nurse perform next?
After determining a client has a problem, which action should the nurse perform next?
What explanation is most appropriate for the behavior of the Hispanic parents offering only broth to their child post-surgery?
What explanation is most appropriate for the behavior of the Hispanic parents offering only broth to their child post-surgery?
What is the best response by the nurse when a client becomes upset upon seeing his colostomy?
What is the best response by the nurse when a client becomes upset upon seeing his colostomy?
Which instruction should the nurse provide when a UAP places a client in a left lateral position for a soap suds enema?
Which instruction should the nurse provide when a UAP places a client in a left lateral position for a soap suds enema?
How much diuretic metolazone (Zaroxolyn) should the nurse plan to administer if it is available in 5 mg tablets?
How much diuretic metolazone (Zaroxolyn) should the nurse plan to administer if it is available in 5 mg tablets?
What is the best position for an elderly male client receiving tube feedings via a gastrostomy tube?
What is the best position for an elderly male client receiving tube feedings via a gastrostomy tube?
What narrative documentation should the nurse enter when a client refuses blood tests?
What narrative documentation should the nurse enter when a client refuses blood tests?
What nursing action should the nurse implement when observing a client's wife supporting the client's arm correctly during passive range-of-motion exercises?
What nursing action should the nurse implement when observing a client's wife supporting the client's arm correctly during passive range-of-motion exercises?
What information should the nurse obtain first from a young mother complaining of increased anxiety?
What information should the nurse obtain first from a young mother complaining of increased anxiety?
What immediate action should the nurse take if the TPN solution has run out?
What immediate action should the nurse take if the TPN solution has run out?
Which action should the nurse take when observing pain and irritation at the infusion site for a client receiving a cephalosporin antibiotic?
Which action should the nurse take when observing pain and irritation at the infusion site for a client receiving a cephalosporin antibiotic?
What information should the genogram provide during a client's health assessment?
What information should the genogram provide during a client's health assessment?
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
What intervention has the highest priority in decreasing the client's risk of infection for those with burns?
What intervention has the highest priority in decreasing the client's risk of infection for those with burns?
Which laboratory value is the most reliable indicator of chronic protein malnutrition?
Which laboratory value is the most reliable indicator of chronic protein malnutrition?
Which action should the nurse take next if the operative permit is not signed and the client has questions about the surgery?
Which action should the nurse take next if the operative permit is not signed and the client has questions about the surgery?
Which factor in a client's history poses the greatest threat for complications during surgery?
Which factor in a client's history poses the greatest threat for complications during surgery?
Which procedure is best for the nurse to follow when assisting a client from the bed to a chair?
Which procedure is best for the nurse to follow when assisting a client from the bed to a chair?
Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply)
Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply)
Which instruction should the nurse provide to ensure optimal benefits from using a metered-dose inhaler?
Which instruction should the nurse provide to ensure optimal benefits from using a metered-dose inhaler?
Which action should the nurse take first regarding a client who has refused to shower during her period?
Which action should the nurse take first regarding a client who has refused to shower during her period?
What is the best response by the nurse when the client notes that a newly prescribed medication reduces sexual drive?
What is the best response by the nurse when the client notes that a newly prescribed medication reduces sexual drive?
What should the nurse document when a comatose client winces and pulls away from a painful stimulus?
What should the nurse document when a comatose client winces and pulls away from a painful stimulus?
How many milliliters should the nurse administer for diazepam, 4 mg IV push?
How many milliliters should the nurse administer for diazepam, 4 mg IV push?
Which intervention(s) are correct when preparing to insert a nasogastric tube? (Select all that apply)
Which intervention(s) are correct when preparing to insert a nasogastric tube? (Select all that apply)
Which observation indicates that the caregiver has learned how to use a gait belt correctly?
Which observation indicates that the caregiver has learned how to use a gait belt correctly?
Which nursing diagnosis has the highest priority for a client with an indwelling urinary catheter?
Which nursing diagnosis has the highest priority for a client with an indwelling urinary catheter?
Which client instruction is important for altered sleep patterns related to nocturia?
Which client instruction is important for altered sleep patterns related to nocturia?
What is the best action for the nurse regarding an opened normal saline labeled 48 hours prior?
What is the best action for the nurse regarding an opened normal saline labeled 48 hours prior?
Which intervention is best for providing care for an older incontinent client at risk for infection?
Which intervention is best for providing care for an older incontinent client at risk for infection?
What should the nurse do when unable to distinguish the first sound while taking a client's blood pressure?
What should the nurse do when unable to distinguish the first sound while taking a client's blood pressure?
What action should the nurse take first when a client's blood pressure reading is 156/94 mm Hg?
What action should the nurse take first when a client's blood pressure reading is 156/94 mm Hg?
What is the most likely outcome of a malpractice lawsuit against a nurse who rendered aid at a collision site?
What is the most likely outcome of a malpractice lawsuit against a nurse who rendered aid at a collision site?
Which intervention should be included in the instruction for preventing complications of immobility?
Which intervention should be included in the instruction for preventing complications of immobility?
Which method is best for evaluating the client's ability to perform a dressing change at home?
Which method is best for evaluating the client's ability to perform a dressing change at home?
Which meal best meets the dietary needs of a client with cholecystitis?
Which meal best meets the dietary needs of a client with cholecystitis?
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
What change in pharmacokinetic properties should the nurse anticipate when a client's prescription changes from PO to IV?
What change in pharmacokinetic properties should the nurse anticipate when a client's prescription changes from PO to IV?
After abdominal surgery, which action should the nurse implement when an older client requests to go to the bathroom?
After abdominal surgery, which action should the nurse implement when an older client requests to go to the bathroom?
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
Which instruction is most important for the nurse to include for a client with limited mobility to prevent venous thrombosis?
Which instruction is most important for the nurse to include for a client with limited mobility to prevent venous thrombosis?
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
Which stool characteristics should the nurse report to the health care provider as soon as possible?
Which stool characteristics should the nurse report to the health care provider as soon as possible?
How should the nurse respond when a client expresses a desire to die?
How should the nurse respond when a client expresses a desire to die?
Which document should the nurse use to develop nursing guidelines for a new mental health services department?
Which document should the nurse use to develop nursing guidelines for a new mental health services department?
Which client is most likely to be at risk for spiritual distress?
Which client is most likely to be at risk for spiritual distress?
Which intervention is most important in the care plan for a client at high risk for postoperative thrombus formation?
Which intervention is most important in the care plan for a client at high risk for postoperative thrombus formation?
Which nonverbal action should the nurse implement to demonstrate active listening?
Which nonverbal action should the nurse implement to demonstrate active listening?
What is the most appropriate response for a nurse when a seriously ill client expresses a desire to die?
What is the most appropriate response for a nurse when a seriously ill client expresses a desire to die?
Which observation during a UAP's blood pressure procedure requires the nurse's intervention?
Which observation during a UAP's blood pressure procedure requires the nurse's intervention?
During a clinic visit, what environmental factor should the nurse assess for a child having difficulty going to sleep?
During a clinic visit, what environmental factor should the nurse assess for a child having difficulty going to sleep?
What should the nurse do first when a 2-year-old's peripheral IV rate is slowing?
What should the nurse do first when a 2-year-old's peripheral IV rate is slowing?
What is the primary benefit of performing range-of-motion exercises?
What is the primary benefit of performing range-of-motion exercises?
What dietary considerations are important for clients with cholecystitis?
What dietary considerations are important for clients with cholecystitis?
The son has the right to waive informed consent for his mentally incompetent mother.
The son has the right to waive informed consent for his mentally incompetent mother.
Which action is most important for the nurse to implement when obtaining a lie-sit-stand blood pressure reading?
Which action is most important for the nurse to implement when obtaining a lie-sit-stand blood pressure reading?
What is the best intervention for a client who is angry about waiting to smoke?
What is the best intervention for a client who is angry about waiting to smoke?
Which serum laboratory value should the nurse monitor for a client with an NG tube to suction for a week?
Which serum laboratory value should the nurse monitor for a client with an NG tube to suction for a week?
What is the best response for a client asking about drinking juice daily to prevent urinary tract infections?
What is the best response for a client asking about drinking juice daily to prevent urinary tract infections?
What should the nurse document as the client's respiratory rate if a count of six respirations is followed by a cough and a second count shows eight respirations?
What should the nurse document as the client's respiratory rate if a count of six respirations is followed by a cough and a second count shows eight respirations?
Which health promotion brochure is most important for a client with arteriosclerosis?
Which health promotion brochure is most important for a client with arteriosclerosis?
What is the nurse's first action when finding a client crying behind a locked bathroom door?
What is the nurse's first action when finding a client crying behind a locked bathroom door?
What should the nurse implement first for a client who has not had a bowel movement in 2 days?
What should the nurse implement first for a client who has not had a bowel movement in 2 days?
Which instruction is most important for a nurse to provide to a client with sacral redness?
Which instruction is most important for a nurse to provide to a client with sacral redness?
What should the nurse do next after inserting a urinary catheter with no urine output in a postoperative client?
What should the nurse do next after inserting a urinary catheter with no urine output in a postoperative client?
Which nursing action is best when discussing a client's depression with a healthcare provider in a public area?
Which nursing action is best when discussing a client's depression with a healthcare provider in a public area?
What should the nurse do first for a client unable to sleep despite following a routine?
What should the nurse do first for a client unable to sleep despite following a routine?
What should the nurse do after a client shows signs of confusion post-operative consent?
What should the nurse do after a client shows signs of confusion post-operative consent?
What is the first assessment the nurse should perform for a client struck by lightning and feeling faint?
What is the first assessment the nurse should perform for a client struck by lightning and feeling faint?
What should the nurse do if parental consent for administering an antipsychotic medication to an adolescent client has not been obtained?
What should the nurse do if parental consent for administering an antipsychotic medication to an adolescent client has not been obtained?
What action is best when a client in a hospital reports difficulty sleeping?
What action is best when a client in a hospital reports difficulty sleeping?
What is the nurse's priority action when a client feels faint while walking to the bathroom?
What is the nurse's priority action when a client feels faint while walking to the bathroom?
What should the nurse do in response to a client asking for a pain pill while laughing?
What should the nurse do in response to a client asking for a pain pill while laughing?
What is the best response for a client expressing concerns about her sexual relationship due to obesity?
What is the best response for a client expressing concerns about her sexual relationship due to obesity?
What intervention is most important when a postoperative client's respiratory rate increases from 18 to 24 breaths per minute?
What intervention is most important when a postoperative client's respiratory rate increases from 18 to 24 breaths per minute?
What is the first action a nurse should take when assigned to care for a close friend in a hospital?
What is the first action a nurse should take when assigned to care for a close friend in a hospital?
What should the nurse encourage the client to do if questions arise about a newly prescribed medication?
What should the nurse encourage the client to do if questions arise about a newly prescribed medication?
What action should the nurse take when observing an ambulatory client walking alone during a fire evacuation?
What action should the nurse take when observing an ambulatory client walking alone during a fire evacuation?
What action should the nurse implement after a needle stick occurs while removing the cap from a sterile needle?
What action should the nurse implement after a needle stick occurs while removing the cap from a sterile needle?
What should the nurse do after emptying 350 mL of pale yellow urine from a client's urinal, noting it's the first void in 4 hours?
What should the nurse do after emptying 350 mL of pale yellow urine from a client's urinal, noting it's the first void in 4 hours?
What action should the nurse include when administering liquid potassium chloride through a feeding tube?
What action should the nurse include when administering liquid potassium chloride through a feeding tube?
If an antihypertensive medication is missing from a client's postoperative prescriptions, what should the nurse do?
If an antihypertensive medication is missing from a client's postoperative prescriptions, what should the nurse do?
What should the nurse do first when administering medications through a nasogastric tube connected to low intermittent suction?
What should the nurse do first when administering medications through a nasogastric tube connected to low intermittent suction?
For documentation of IV catheter placement in the client's right arm, which should the nurse record?
For documentation of IV catheter placement in the client's right arm, which should the nurse record?
What client statement requires further assessment of the medication order during medication administration?
What client statement requires further assessment of the medication order during medication administration?
What is the best action to take when providing wound care instructions to a client who does not speak English?
What is the best action to take when providing wound care instructions to a client who does not speak English?
What assessment data provides the most accurate determination of the proper placement of a nasogastric tube?
What assessment data provides the most accurate determination of the proper placement of a nasogastric tube?
What should the nurse realize about the center of gravity for an elderly person during ambulation assistance?
What should the nurse realize about the center of gravity for an elderly person during ambulation assistance?
What is the most important action for the nurse to implement when donning sterile gloves?
What is the most important action for the nurse to implement when donning sterile gloves?
What should the nurse say first to a client tired of taking antihypertensive medications who wants to try spiritual meditation instead?
What should the nurse say first to a client tired of taking antihypertensive medications who wants to try spiritual meditation instead?
What is the primary source of information for a health assessment?
What is the primary source of information for a health assessment?
Which comment from a client indicates effective teaching about diet and lifestyle modifications for high cholesterol?
Which comment from a client indicates effective teaching about diet and lifestyle modifications for high cholesterol?
How should the nurse record findings of a rash made up of multiple flat areas of redness on a client's arm?
How should the nurse record findings of a rash made up of multiple flat areas of redness on a client's arm?
What question is most important for the nurse to ask a client who is 5'5'' tall and weighs 200 pounds during a preoperative assessment?
What question is most important for the nurse to ask a client who is 5'5'' tall and weighs 200 pounds during a preoperative assessment?
What action should the nurse take after suctioning a client's trachea for 15 seconds and large amounts of thick yellow secretions return?
What action should the nurse take after suctioning a client's trachea for 15 seconds and large amounts of thick yellow secretions return?
What should the nurse do for a client receiving nasogastric tube feedings who reports severe coughing?
What should the nurse do for a client receiving nasogastric tube feedings who reports severe coughing?
What should the nurse do first for a female client with a nasogastric tube attached to low suction who states she is nauseated?
What should the nurse do first for a female client with a nasogastric tube attached to low suction who states she is nauseated?
Study Notes
Client Safety During Movement
- When turning an immobile client, ensuring bed rails are up on the opposite side prevents falls.
- Using a turn sheet is important but less critical than raising bed rails for safety.
Infection Control in Burn Patients
- Handwashing is the most effective method to prevent infection, especially important for burn patients.
- Topical antibacterial applications and visitor limitations are useful but secondary to proper hand hygiene.
Assessment of Malnutrition
- Low serum albumin levels are a significant indicator of chronic protein malnutrition.
- Serum transferrin has a shorter half-life and is less reliable for chronic assessments compared to albumin.
Preoperative Procedures
- If the operative permit is unsigned, the nurse must inform the surgeon before witnessing the client's signature or answering questions.
Surgical Risks and Anticoagulants
- Anticoagulant use poses a high risk for surgical bleeding complications.
- Birth control pills and antibiotic therapy present lower risks in surgical contexts.
Assisting Clients from Bed to Chair
- Positioning the chair at a correct angle and stabilizing the client's knees enhances safety during transfers.
- Lifting clients under the axillae is dangerous; clients should use the chair's arms for support.
Administering Ear Drops
- Place the client in a side-lying position and pull the auricle upward and outward for effective ear drop administration.
- Cotton should be placed in the outer canal only, and the dropper should be 1 cm above the ear canal.
Proper Use of Metered-Dose Inhalers
- Inhalers should be administered while inhaling slowly through the mouth, optimizing medication delivery to the lungs.
Addressing Personal Hygiene Concerns
- Educating clients about proper hygiene during menstruation is essential when addressing their beliefs about bathing.
Neurological Assessments with Glasgow Coma Scale
- Document purposeful responses to painful stimuli; assess responses to verbal commands next.
Medication Administration Calculations
- Accurate calculations are key. For diazepam IV push: 4 mg equals approximately 0.8 mL.
Nasogastric Tube Insertion Protocol
- Position the client upright and instruct them to swallow when the tube passes the pharynx, ensuring proper insertion technique.
Gait Belt Usage for Ambulation
- Caregivers should stand on the weak side of the client when using a gait belt for safety and support.
Infection Risks with Urinary Catheters
- High risk for infection is the priority concern when caring for clients with indwelling urinary catheters.
Managing Nocturia
- Reducing fluid intake after the evening meal helps decrease nocturia, improving sleep.
Sterile Technique in Wound Care
- Discard any opened saline solution older than 24 hours to maintain sterility during wound care.
Infection Prevention for Incontinent Clients
- Maintaining standard precautions is crucial to prevent infection in older, incontinent clients.
Blood Pressure Measurement Techniques
- Wait 30-60 seconds after deflating the cuff to ensure an accurate second blood pressure reading.
Legal Protections in Emergency Situations
- The Good Samaritan Act protects the nurse from malpractice claims when providing reasonable care in emergencies.
Ethical Considerations for Informed Consent
- Health providers must obtain informed consent to avoid negligence, even if family members believe the patient cannot handle the information.
Safety During Blood Pressure Readings
- Staying with the client while standing is crucial for their safety during blood pressure measurements.
Client Anger Management
- Review the schedule of breaks with an agitated client, providing clear communication and managing expectations.### Nursing Actions and Rationale
- Reviewing the schedule for outdoor breaks is crucial for maintaining client trust and communication.
- Close monitoring of sodium levels is important for clients with prolonged NG suctioning due to potential fluid loss.
Patient Education
- Cranberry juice is effective in preventing urinary tract infections (UTIs) by reducing bacterial adherence to the bladder.
Respiratory Assessment
- Document the respiratory rate based on the most accurate count, which should not include interruptions from coughing.
Health Promotion
- Focus on decreasing cholesterol intake as it is a significant risk factor for arteriosclerosis, more so than other factors such as smoking cessation or stress management.
Client Emotional Support
- Engage directly with clients in distress to assess their situation and provide immediate support.
Bowel Movement Assessment
- Assess a client’s normal bowel patterns before implementing interventions for constipation.
Pressure Ulcer Prevention
- Encourage frequent position changes for clients to prevent pressure ulcers, particularly in wheelchair users.
Urinary Catheterization Procedure
- If urine is not produced during catheterization, leave the initial catheter in place and attempt a second catheterization to correctly locate the bladder.
Maintaining Client Confidentiality
- It is essential to discuss client issues in private to maintain confidentiality, avoiding discussions in public areas.
Sleep Promotion Techniques
- Assess a client's current sleep routine before introducing changes to their care plan for insomnia.
Postoperative Client Monitoring
- Assess neurological status if a client expresses confusion after signing a consent form to ensure understanding and legality of consent.
Initial Assessment Following Injury
- First assess the client's pulse rate and regularity after being struck by lightning due to the risk of electrical injury.
Medication Administration for Minors
- Withhold medication from minors until proper parental consent is obtained, ensuring documented reasoning for the decision.
Enhancing Sleep Hygiene
- Incorporate a client's typical bedtime routine into their care plan to improve sleep quality.
Fall Prevention in Clients
- Prioritize gently lowering a client who feels faint to the floor to prevent injury rather than seeking immediate medical assessment.
Pain Assessment
- Utilize a pain scale to evaluate a client's pain experience, guiding appropriate medication administration.
Addressing Client Concerns
- Invite clients to share specific concerns to facilitate open communication and effective counseling regarding sensitive topics like sexuality.
Respiratory Rate Interventions
- Investigate the cause of tachypnea in postoperative clients, prioritizing the assessment of pain, anxiety, or fluid accumulation.
Professional Boundaries
- Communicate openly with charge nurses about assignments involving close friends to maintain professional boundaries.
Immobility Complications Prevention
- Perform range-of-motion exercises with immobile clients to reduce the risk of contractures and other complications.
Client Competence Evaluation
- Assess a client's ability to perform self-care tasks like dressing changes through direct observation for accuracy.
Nutrition and Dietary Needs
- Recommend low-fat foods for clients with cholecystitis to manage their dietary restrictions.
Hygiene Practices for Children
- Gently retract the foreskin in uncircumcised boys over three years for proper cleaning to prevent infection.
Pharmacokinetics of Medication Routes
- Transitioning medications from PO to IV can lead to a faster onset of action, as IV administration eliminates the absorption phase.### Client Safety and Care
- Assist clients to the bathroom to minimize fall risks, especially when they are on CNS depressive medications.
- The use of a bedpan is unnecessary as long as client safety is ensured; assess the client's ability to communicate needs.
- Regular dorsiflexion and plantarflexion are critical for clients with limited mobility to prevent venous thrombus formation.
- Checking bath water temperature is essential to prevent burns when preparing an older client for a tub bath.
Stool Characteristics
- Black, sticky stool (melena) indicates possible gastrointestinal bleeding and requires prompt reporting to a healthcare provider.
Client Management
- Reassure apprehensive clients calmly when they express fears about procedures; this can help reduce anxiety.
- Encourage clients facing terminal illnesses to pursue goals that bring them joy, such as planning a gathering with friends.
- Observing blood pressure techniques is crucial; auscultation should be done at the proper site (popliteal pulse) when measuring in the lower extremities.
Grief and Mental Health
- Assess the family environment for contributing factors when school-age children present sleep resistance; this is vital for promoting healthy sleep habits.
- Grief counseling is essential for clients exhibiting normal grief behaviors after losing loved ones.
Medication Administration
- Encourage clients to reach out with questions about medication, emphasizing the importance of consulting healthcare providers.
- Follow proper protocols for medication administration through feeding tubes, including flushing with water between doses.
Emergency Situations
- During evacuations (e.g., fire), ambulatory clients should be reminded to navigate safely, without requiring assistance like a wheelchair.
- After a needle stick, dispose of the used needle safely and select a new one, rather than trying to disinfect the contaminated needle.
Postoperative Care
- Medications prescribed preoperatively need to be renewed after surgery; contact healthcare providers if they are absent from postoperative orders.
- Confirm nasogastric tube placement before administering medications, and turn off suction to facilitate proper medication absorption.
Documentation
- Accurate documentation of IV placement is crucial for ongoing care; ensure the correct identification of vein and location used for insertion.
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Description
Test your knowledge on essential nursing safety protocols and infection control measures for patients. This quiz covers key topics like client mobility, infection prevention for burn victims, malnutrition assessment, and preoperative nursing responsibilities.
